Five attributes of health plans poised to win

The implementation of the Affordable Care Act (ACA) set off a seismic shift in the way healthcare functions in the U.S., and consequently, how industry organizations conduct business.

In addition to reconfiguring reimbursement models that hinge on the value vs. volume of care provided, health plans in particular are increasingly held more accountable. Stronger plan performance hinges on keeping costs down, increasing member satisfaction, driving quality imperatives that result in better clinical outcomes, and maintaining programs that are compliant with government guidelines and accreditations.

PaddaThe Centers for Medicare and Medicaid Services estimates that by 2018, 90% of payment programs will take the form of value-based models. Today’s value-focused economy was a primary discussion point at a recent roundtable event, hosted by Health Integrated, which convened health plan CEOs and other leaders from across the country.

Candid discussions about what it will take to succeed in the value-based environment led to five essential attributes that organizations must embrace to thrive in the drive to value-based healthcare.

1. Use of data

Leveraging insights from the past is one of the surest ways to ensure positive change in the future. For health plans, the use of available patient data is one piece of the puzzle in the quest toward bettering health outcomes and lowering usage and costs for payers.

While traditional claims data is invaluable, other data sources, such as intel from pharmacies on medication use, the number and type of prescribing providers involved in treatment, and dosage amounts, can help fill in the blanks of patient medical history and health status.

When examining patient data to help drill down on root causes of healthcare utilization beyond traditional clinical information, it’s important to remember that there are other factors to take into account to achieve a more comprehensive, holistic view. Consider that 80%of health issues are impacted by behavioral and social factors, a statistic that sheds light on a larger issue: the need for truly integrated care.

Accounting for and addressing hidden cost drivers, in combination with the use of actionable data, can help strengthen health plan profitability and provide the competitive edge necessary to succeed.

Next: The second essential attribute

2. Recognition of shifts in care delivery

Adapting to non-traditional methods for care delivery is essential for health plan success. The industry shift in care delivery can be viewed as occurring in two main, though often overlapping, areas: where care is delivered, and by whom.

Patient care in non-clinical settings is on the rise for several reasons. More Baby Boomers reach retirement age every day, and many members of the population-approximately 50% living with one or more chronic diseases-will seek care in a non-hospital setting. Due to consumer preference and nursing homes being cost-prohibitive for many Americans, many patients’ only alternative is to receive care in the home, often by a family caregiver or visiting nurse.

Access and how providers adapt to demand is changing as well. A recent Gallup Poll found that nearly 90% of Americans now have health insurance. While the ACA dramatically improved access to health care, it simultaneously burdened providers who were inundated with a massive volume of newly insured patients seeking care. Increased patient volume and a lack of primary care providers have translated into the need for nurses and nurse practitioners to take on greater responsibility in patient care.

Health plans that modify their operational models to support alternatives to care delivery venues and personnel will be well-positioned for success.

Next: The third essential attribute

3. Focus on the consumer

Consumers are at the core of the transition from fee-for-volume to fee-for-value. Optimizing the consumer healthcare experience leads to consumer satisfaction, which leads to a healthier and happier population.

With consumers top-of-mind, it’s vital that health plans remember that convenience is king. It’s also inextricably linked to value; engaging consumers is necessary in order to provide quality, effective care, lower costs, and improved health.

The rise and success of healthcare services, including retail clinics and pharmacies offering expanded services such as annual vaccinations and children’s sports physicals, and mobile apps that allow consumers to “order” a physician house call with just a few finger swipes, is a testament to the demand for services that save patients time and money.

One of the attending health plan CEOs put it simply: “Reaching, engaging, and delighting members” is now a necessity, and should be on every health plan’s agenda.

Next: The fourth essential attribute

4. Use of digital and mobile

A Pew Research Center study made public earlier this year found that 64%of American adults own a smartphone, and 62%of smartphone owners have used their devices to seek information about their health.

It’s no secret that the use of digital and mobile tools enables access and promotes uninterrupted flow of information, but the transition from paper files to electronic health records and an industry-wide push for interoperability is only part of the picture.

Next: The fifth essential attribute

5. Willingness to innovate

The saying, “The only thing that is constant is change” resonates across many sectors, and particularly across the rapidly evolving health care landscape. Three years ago, would any of us have expected the construction of hospitals devoid of patient beds?

An organization’s clear understanding of the steps necessary to achieve positive results is imperative.

Healthcare executives need to accept that change begins with leadership, bleeds into organizational culture, and translates into the learning of new competencies and alignment on incentives.

Bottom line, health plans that fail to adapt to requirements of today’s value-based economy will not succeed. Agility and forward-thinking are essential. Without them, plans will be left behind.

Shan Padda serves as chairman and CEO of Health Integrated. Under his direction, Health Integrated enables health plans to effectively manage their most vulnerable members and control costs by combining actionable big data with its proprietary integrated care management model to address the physical, psychological and social drivers impacting a member’s health and plan performance.